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SAN JOAQUIN <br /> Environmental Health Department <br /> lhI I Y <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW: <br /> 9 TANK RETROFIT U PIPING REPAIR/RETROFIT U UDC REPAIR/RETROFIT U COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # (425) 251 -6222 <br /> C Facility Name Costco Wholesale # 1031 ) <br /> Phone # (209 825-8200 <br /> I <br /> L Address 2440 Daniels Street , Manteca , CA 95336 <br /> I Cross Street <br /> T <br /> Y Owner/Operator Warehouse Manager Phone # (209) 825-8200 <br /> `✓ Contractor Name Wayne Perry , Inc . Phone # (714) 826- 0352 <br /> O Y Y <br /> N <br /> T Contractor Address 8281 Commonwealth Ave . CA Lic # 300345 Class A B C10 HAZ <br /> R an Work Com # <br /> Insurer Everest National Insurance Company p y p CA10003737- 181 <br /> T <br /> T ICC Technician 's Name Gonzalo Gomez Expiration Date 2/12/2020 <br /> RICC Installer's Name Gonzalo Gomez Expiration Date 1 /5/2020 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e. 87 piping sump, 91 leak detector, UDC 1 /2, etc.) Installed <br /> T Install additional 2hp Turbine Pump on Tank 1 30 , 000 Gallons 87 Unleaded Gasoline 05/01 /2008 <br /> A Install additional 2hp Turbine Pump on Tank 2 30 , 000 Gallons 87 Unleaded Gasoline 05/01 /2008 <br /> N <br /> K Install additional 2hp Turbine Pump on Tank 3 30 , 000 Gallons 91 Premium Gasoline 05/01 /2008 <br /> Install 4 additional Multi Product Dispensers <br /> Removal of existing piping to Western Dispensers <br /> Relocation of the Vent Stack and Vent Sump. Replacing <br /> the Healy Clean Air Separator with Arid Permeator <br /> P ❑ Approved wo Approved with conditions ❑ Disapproved <br /> L ( S tachment With Conditions ) <br /> A ( ( ( f <br /> N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES , STATE LAWS , AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANC _ OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMP ATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING : " I CERTIFY <br /> THAT IN THE PER O MANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED , I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signatur Title Project Manager Date 12/ 10/ 19 <br /> BILLING INFORMATION : <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br /> tank. If the party designated below is different than the permit applicant , e . g . property owner, the party must <br /> acknowledge this responsibility for the billing by signature and date below. <br /> NAME Alexia Inigues TITLE Senior Planner PHONE # (425) 251 -6222 <br /> ADDRESS 18215 72nd Avenue South , Kent , Washington 98122 <br /> SIGNATURE ..,�. .� . DATE <br /> 2of6 <br />